# A 65-year-old female client received intravenous morphine 30 minutes ago for postoperative pain. The surgeon has just placed an open-thoracotomy informed consent form on the bedside table and asked the nurse to obtain the signature of the client before the second-stage procedure scheduled in 1 hour. The client appears drowsy, has slurred speech, and asks the nurse to explain the procedure again. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=362206&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

A 65-year-old female client received intravenous morphine 30 minutes ago for postoperative pain. The surgeon has just placed an open-thoracotomy informed consent form on the bedside table and asked the nurse to obtain the signature of the client before the second-stage procedure scheduled in 1 hour. The client appears drowsy, has slurred speech, and asks the nurse to explain the procedure again. Which is the priority nursing action?

## Option

1. Defer obtaining the signature, document the current sedation level (drowsy, slurred speech), and notify the surgeon that the client lacks capacity to provide informed consent at this time. **✔ Correct answer**
2. Ask the client's spouse to sign the consent form as a surrogate, because the client is too drowsy to consent, the procedure is scheduled soon, and the surgeon needs it signed now.
3. Read the consent form aloud to the client, ask the client to repeat back the main points of the procedure, and have the client sign if able to repeat them accurately.
4. Witness the client's signature on the consent form, since the surgeon explained the procedure earlier, the client nodded in agreement, and the nurse's role is to witness the signature, not assess capacity.

**Correct answer: 1**

## Explanation

Informed consent requires the client to have decision-making capacity at the moment of signing — alert, oriented, free from significant sedation, and able to understand the procedure, risks, benefits, and alternatives. Recent IV morphine combined with current drowsiness and slurred speech indicates impaired capacity. The priority nursing action is to defer the signature, document the sedation level, and notify the surgeon. The surgeon may delay the procedure, allow the morphine to wear off, or pursue an alternative pathway (advance directive, healthcare proxy) per facility policy. Option 4 — witnessing a signature from a sedated client is a legal and ethical violation regardless of when the surgeon explained. Option 3 — reading the form and requesting repeat-back does not restore capacity; sedation is the disqualifying factor. Option 2 — a family member cannot sign as surrogate while the client retains capacity (or before formal capacity loss is documented per state law); proceeding for scheduling reasons violates patient autonomy.

## In-depth explanation

Clinical Judgment
Apply NCJMM: Recognize cues (recent IV morphine, drowsiness, slurred speech, request to re-explain) → Analyze cues (sedation impairs capacity; consent obtained now would be invalid) → Generate solutions (defer + document + notify surgeon) → Take action (do not witness, document sedation, notify) → Evaluate outcomes (consent will be valid only after capacity returns or after a legitimate surrogate process).

Memory Tip
No capacity = No consent. Sedation, intoxication, significant dementia, or severe pain all disqualify the patient from giving informed consent. Nurse role = witness that consent is given freely and competently — not coach the patient through it.

KR vs US
Korean practice often allows family members to sign on behalf of the patient. In the US, when the patient has capacity, the patient signs personally. If capacity is temporarily impaired, the surrogate process (advance directive, or next-of-kin per state law) applies. NCLEX always treats signing after analgesic dosing or bypassing through a family surrogate as wrong.

## Clinical scenario

Clinical Practice Guide
AHA / Joint Commission informed consent standards: capacity assessment includes (1) comprehension of the proposed procedure, (2) understanding of risks/benefits/alternatives, (3) ability to make and communicate a decision, and (4) absence of significant impairment (sedation, intoxication, severe psychiatric symptoms). The provider obtains consent; the nurse witnesses and verifies that the signature is voluntary and the client appears capable.

Caution
Common NCLEX traps: (1) "the surgeon already explained" → capacity is still required at signing, (2) "family signs while client is sedated" → bypasses autonomy and the legal hierarchy, (3) "have the client repeat back to confirm" → does not restore capacity from sedation. The fix is always to defer, document, and notify the surgeon.

## Key concepts

- **Decision-making capacity** — The clinical and legal ability to (a) understand a proposed procedure and its risks/benefits/alternatives, (b) appreciate how it applies to oneself, (c) reason through choices, and (d) communicate a decision. Capacity can fluctuate (sedation, delirium, intoxication) and is assessed at the moment of signing.
- **Informed consent** — A legal and ethical process in which a competent patient voluntarily agrees to a procedure after receiving and understanding adequate information about the diagnosis, the proposed intervention, risks, benefits, alternatives, and the option to refuse. The provider obtains the consent; the nurse witnesses and verifies voluntariness and apparent capacity.
- **Surrogate decision-maker hierarchy** — The order in which decisions are made when a patient lacks capacity: (1) advance directive / healthcare proxy, (2) court-appointed guardian, (3) spouse, (4) adult children, (5) parents, (6) adult siblings, (7) close friend (per most state laws — order may vary by jurisdiction). Used only when the absence of capacity is formally documented.

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